tissue integrity part two Flashcards
Pressure ulcer
also called pressure injury, localized injury to skin and/or underlying tissue
where are pressure ulcers usually at
bony prominences
how do pressure injuries occur
prolonged pressure for a prolonged period of time
pathophysiology of pressure ulcers
prolonged period of time –> stops capillary flow to tissue –> deprives tissues of oxygen and nutrients –> cell death and tissue necrosis
pressure intensity
amount of pressure
pressure duration
length of time pressure is exerted on skin
tissue tolerance
ability of tissue to tolerate the presure
tissue tolerance factors
nutrition, perfusion, co-morbidities, condition of soft tissue
shearing forces
when skin adheres to a surface and skin layers slide in the direction of body movement
moisture
Excessive moisture that leads to skin breakdown
what is staging based on
NPUAP
NPUAP
national pressure ulcer advisory panel
deep tissue injury
purple or maroon localized area of discolored intact skin or blood filled blister
what does a deep tissue injury indicate?
damage of underlying soft tissue from pressure or shear
Stage one
intact skin, non-blanchable
stage two
partial-thickness loss of dermis, shallow open ulcer
stage three
Can see subcutaneous tissue, full thickness skin loss
stage four
extends to muscle, bone, or supporting structures, full thickness loss
unstageable ulcer
Full-thickness loss but actual depth can not be seen because view is obstructed
untreated ulcers may lead to
cellulitis
most common complication of pressure ulcers
recurrence of tissue breakdown/repeat pressure ulcers
signs of infection of pressure ulcers
swelling, redness, and foul odor
what can cellulitis lead to
sepsis leading to death
leukocytosis
high white blood cell account
pressure ulcer prevention
Redistribution of pressure, dry skin, repositioning, turning schedule, nutrition and fluid intake
greatest treatment for pressure ulcers
Prevention
prevent (1)
deterioration
reduce (2)
factors that contribute to pressure and skin breakdown
prevent (3)
infection
promote (4)
healing
prevent (5)
recurrence
what do you document for a pressure injury
stage, size, location, exudate, infection, pain, and tissue appearance
MASD
moisture associated skin damage
IAD
incontinence associated dermatitis
MARSI
medical adhesive related skin injury
lower extremity ulcers
related to changes in blood flow to lower extremities or chronic disease
arterial ulcers
caused by problems with blood flow in arteries, ischemia, nutrition deprivation
venous leg ulcers
blood cannot flow upward from veins in the legs
wound margins and thickness of venous leg ulcers
irregular, superficial
wound margins and thickness of arterial ulcers
even, deep
diabetic ulcers
caused by peripheral neuropathy, fissures in the skin, and decreased ability to fight infection
wound margins of diabetic foot ulcers
even
cellulitis
deep inflammation of subcutaneous tissue caused by enzymes produced by bacteria, often after break in the skin
antibiotic resistance
the emergence of resistance to antibiotics
can viral infections be treated with antibiotics?
No
how does antibiotic resistance happen
taking too many antibiotics OR not finishing your prescription
psoriasis
plaque formation with varying degrees of severity
tell-tale signs of psoriasis
silvery scales
